In this episode, we’ll be discussing the paper entitled, “Managing risk in hazardous conditions: improvisation is not enough” by Rene Amalberti and Charles Vincent (2019), published in BMJ Quality & Safety. Though the paper is focused on the healthcare industry, we can extrapolate the findings to safety in other industries. We’ll discuss the need for different or modified levels of acceptable safety measures in “degraded operations” when 100% adherence to safety rules is simply not possible.
The paper’s abstract reads:
Healthcare systems are under stress as never before. An aging population, increasing complexity and comorbidities, continual innovation, the ambition to allow unfettered access to care, and the demands on professionals contrast sharply with the limited capacity of healthcare systems and the realities of financial austerity. This tension inevitably brings new and potentially serious hazards for patients and means that the overall quality of care frequently falls short of the standard expected by both patients and professionals. The early ambition of achieving consistently safe and high-quality care for all has not been realised and patients continue to be placed at risk. In this paper, we ask what strategies we might adopt to protect patients when healthcare systems and organisations are under stress and simply cannot provide the standard of care they aspire to.
- Extrapolating out from the healthcare focus to other businesses
- This paper was published pre-pandemic
- Adaptations during times of extreme stress or lack of resources – team responses will vary
- People under pressure adapt, and sometimes the new conditions become the new normal
- Guided adaptability to maintain safety
- Substandard care in French hospitals in the study
- The dynamic adjustment for times of crisis vs. long-term solutions
- Short-term adaptations can impede development of long-term solutions
- Four basic principles in the paper:
- Giving up hope of returning to normal
- We can never eliminate all risks and threats
- Principal focus should be on expected problems
- Management of risk requires engagement and action at all managerial levels
- Griffith university’s rules on asking for an extension…expected surprises
- Middle management liaising between frontlines and executives
- Managing operations in “degraded mode” and minimum equipment lists
- Absolute safety – we can’t aim for 100% – we need to write in what “second best” covers
- Most industries are facing more pressure today than in the past, focus on the current risks
- All industries have constant risks and tradeoffs – how to address at each level
- Understand how pressures are being faced by teams, what adaptations are acceptable for short and long term?
- For expected conditions and hazards, what does “second best” look like?
- Research is needed around “degraded operations”
- Answering our episode question: The wrong answer is to only rely on the highest standards which may not be achievable in degraded operations
“I think it’s a good reflection for professionals and organistions to say, “Oh, okay – what if the current state of stress is the ‘new normal’ or what if things become more stressed? Is what we’re doing now the right thing to be doing?” – David
“There is also the moral injury when people who are in a ‘caring’ profession and they can’t provide the standard of care that they believe to be right standard.” – Drew
“None of these authors share how often these improvised solutions have been successful or unsuccessful, and these short-term fixes often impede the development of longer-term solutions.” – David
“We tend to set safety up almost as a standard of perfection that we don’t expect people to achieve all the time, but we expect those deviations to be rare and correctable.” – Drew